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Why We Need To Stop Rating Pain On A Scale From One To Ten

Whenever you go to A&E or are admitted to a general hospital for a physical illness because of an injury or disease that hurts, you are always asked the same question.

“On a scale from one to ten, how would you rate your pain?”

They make pain sound like a hotel that you recently stayed in on holiday. You know, those hotels where at the end of your stay you are handed a feedback form to let staff know what you thought of the experience provided (although with the pain thing ten tends to mean “the worst pain you have ever felt” and zero “no pain at all”, rather than the hotel ten to zero equivalents of “I found a dead man in my bed” to “the room service was excellent.”) I always find this question a difficult one to answer, which is silly really because it isn’t exactly a question that requires much revision (unlike GCSE biology. I swear I read those text books so many times that I will never forget the fact that most of the energy released during respiration comes from the mitochondria), and really I am the only person who can answer it. Then again, how can you answer such a subjective question and how can you quantify pain? When you are in pain, that is it, all you know is that you are in pain and the ability to rate it on a scale is somewhat diminished by the agony you are experiencing.

Were someone to ask you to rate your pain on a scale seconds after you had just stubbed your toe, most if not all people would probably cry out “10” and then perhaps yell some abuse at the person who was asking such a silly question when they were leaping around with a potentially broken toe. In those moments when the injury has just occurred (aka the toe stubbing), you are unable to rationalise that really, the pain is unlikely to be the worst pain you ever felt. You don’t hear the question and really think about it, employing reason to figure that stubbing your toe was probably a lot less painful than the day you had your whole foot bitten off by a shark (suffice it to say you are rather careless with the body parts that exist below your knees). No, in that pain your stubbed toe is a 10, the worst pain ever, and you would say that whether or not that is true.

The question is then further complicated by the fact that people have different pain thresholds. For example, I use an epilator to remove unwanted hair on my legs (lovely image for you there…enjoy it), and for me the “pain” that causes doesn’t bother me at all because I have been doing it for years and am used to it. My mum on the other hand couldn’t epilate because she finds the process agony, a pain that I have somewhat grown out of fearing through repeated experience. How then can you ask someone to rate their pain when one person’s 10 could be another person’s 4.

All in all the question of rating pain in medical settings is problematic, yet I would say it is far more problematic in the way it is used when it comes to mental health problems.

Whenever you are admitted to a psychiatric hospital or sent to see a new therapist, it is likely you will be given a form to fill out with a lot of questions, scales and little boxes to write numbers in. The questions are differently worded each time but overall they are pretty much the same and include things like “On a scale of one to ten how depressed have you been in the last 28 days” or “In the last 28 days how anxious have you been on a scale of one to ten” (Mental health professionals love measuring time in 28 day blocks. Weirdos.)

I myself have filled in many forms like this over the years, and the questions stump me every time. Asking me to rate how depressed I am with numbers is like that song in the Sound Of Music when all the nuns are singing about the difficulty of solving a problem like Maria being akin to pinning a wave upon the sand. When I am depressed, it simply feels like I am drowning. How on earth can drowning be rated? You can’t be more drowning or less drowning, you are either drowning or you are not, and if it is the first of those options then the important thing is to send out the life boats rather than asking exactly what percentage of your lungs have filled with water. On the most recent questionnaire I filled out I was asked to write a number from 1 to 10 describing “how suicidal” I had felt in the last 28 days and then there were further enquiries as to how many days I had felt that way and what each of those days looked like when rated and compared. What kind of question is that? Can you rate how suicidal you have felt? Much like with the depression question, when I feel suicidal it is a feeling with a depth and breadth far greater than I can put into words, let alone numbers. Never have I ever turned up in a session saying I feel like “a 4” or indeed “a 10”. Instead I try to capture what is going on using any adjectives to hand, hopeless, guilty, lost, useless, depressed, like a waste of space etc, and even those aren’t good enough. Furthermore, if I have been feeling suicidal for a length of time I am unable to distinguish the levels of the feelings with each day that passes because on the day I am asked, the pain I am CURRENTLY experiencing is all I can think about, much like the person with the stubbed toe can only think about their bruised digit. Even if I could distinguish the difference, how can you measure “how suicidal” you are? What are you supposed to think? Should I reflect on my week and think “well Tuesday was clearly better than Wednesday because I only prepared a noose without planning on a place to hang it and working out how to get to such a height? Isn’t the fact that someone is suicidal enough to ring alarm bells? Professionals should hear that pain exists and take action immediately because to feel suicidal at all is incredibly serious and not something that should be dismissed because the form rated the feelings as “1”. If the number is anything other than a 0 in whatever box, the pain should be addressed rather than swept under the carpet as insignificant.

Of course I understand the need to rate pain in the physical illness world and to some extent in the mental illness world as well. If you need to tell a doctor where something hurts, telling them how badly it hurts could be a handy indicator as to what is going on. Indeed I think numbering pain has great value and for a brief glimpse into how life is for a certain person, it has a place, but it is still incredibly limited. I am not saying we should stop rating pain by numbers, I am saying that we need to rate it in other ways too. For people who are scientifically minded maybe numbering things is a helpful way to look at distress. I myself however, am not a mathematical person, I instead deal with words and images. When I am distressed I feel my heart racing at such a rapid pace that I feel it will burst from my chest, when I feel hopeless I can see nothing but a bleak black hole, and when I am overwhelmed the world is a screaming canvas of differently coloured paint splattered chaotically like a Jackson Pollock painting. How on earth am I supposed to get all of that into a little box on a form using a secretary’s leaky biro? Mental illness questionnaires need to offer a variety of ways for people to express themselves, maybe some lined paper so that they can write if the number system is unsuitable, hell maybe a watercolour pad and some paint to at least attempt to capture the uncapturable and intricate complications of the human mind. Patients need to be seen as individuals who all feel and express themselves in a certain way, and the questionnaires they are required to fill out should reflect this.

In my most recent forms, to be honest I found myself writing random numbers in a lot of the boxes (or at least numbers that my head didn’t deem as “dangerous and likely to cause harm to a loved one”), because I couldn’t rank my levels of distress in numerical order and I would be surprised if other people hadn’t had to do similar things just to make the professionals happy when really the idea is that they are trying to help YOU as an individual get better, not YOU helping them fill out their paperwork. Let us explore the diversity of experience in diverse ways, use any method possible to express some of what is going on in the depths of our souls and listen, look, even smell what is really going on rather than capturing it in an insignificant number on a scale of one to ten. We need to focus not on rating the pain but acknowledging that its mere existence is a problem and that if someone is drowning the key is sending out the life boats, not waiting for them to be “more drowning” or to cry out a number that is in double figures. By then who knows? It might be too late.

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6 thoughts on “Why We Need To Stop Rating Pain On A Scale From One To Ten”

This resonates so much. I have to fill out a form every single week (and have been doing so for almost nine months now- I could have had a form-baby!) and I’m now stuck because I consistently score the same because each week feels like I’ve scored it, but then how can I be scoring at the very top end week in week out? Words, as you say, are so much more meaningful to me than stupid scores on my (very dismal) outlook on my life and (very high) wish not to partake in said life. I may have to suggest I add in some extra numbers- perhaps 10.1, or 11.6, because whilst he would balk at the strange use of decimal points, is that really any more bizarre than allocating any kind of number to how despairing/lonely/whatever else you feel that week?!

Urgh I am sorry you have to fill out these forms every single week! That must be so frustrating! I totally agree with you too, words say far more than numbers ever do! Maybe we should make a new form which is more suitable…challenge accepted!

Yesyesyes and a-yes. Rating pain or mental health is such a subjective thing. Coming from someone who has just been handed bunch of these questionnaires to fill out for tomorrow I am NOT looking forward to having to quantify my mental health for others to judge. Plus it becomes more of a fuzzy grey area when you’re so used to feeling a certain way that sometimes even if looking back it was a 10 you sometimes only feel it deserves a 6 because you’re sure it’s probably not as bad as you’re making it out to be!

With that being said I feel this number scale can come in handy at a more personal level. I often find in the midst of a particularly bad brain day I am unable to describe how I’m feeling so it’s often handy to use a scale to relay to others how bad I’m feeling in comparison to my usual days. I suppose the same goes for a therapist who has taken the time to get to know you and your case and understands your various moods.

Omg you called me your courgetti and I am instantly honoured! You are the best! I also totally agree with you on this one, there are too many fuzzy great areas with mental health and often when you look back on scores they are different in retrospect because you are able to rationalise more rather than get caught up in the moment. However I do also see where you are coming from what with the scale being handy at a personal level, I think my main problem is when it is used by professionals to assess everything. Ahh well, I suppose they have to assess things some how! Hope your forms went through ok anyway, much love my fellow courgetti! xxxxx